Basic Information
| Provider Information | |||||||||
| NPI: | 1558712422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OZARK TRI COUNTY HEALTHCARE CONSORTIUM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ACCESS FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 758 | ||||||||
| Address2: | |||||||||
| City: | NEOSHO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648500758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174519450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 204 N CEDAR | ||||||||
| Address2: | |||||||||
| City: | NEVADA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175496845 | ||||||||
| FaxNumber: | 4175496836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAY | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | GRANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4174519450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.